I write as both a doctor and a social scientist and here I focus on some of the connections between social conditions and health.
In a 2017 paper called ‘The Health Gap’, which summarised his 2016 book, Sir Michael Marmot challenged the assumption that disease prevention is mainly about individual behaviour – eat the right food, don’t smoke, take exercise and so on. He cited a list of alternative instructions:
- Don’t be poor. If you can, stop being poor. If you can’t stop being poor, try not to be poor for long.
- Don’t live in a deprived area. If you do live in a deprived area, move.
- Don’t be disabled or have a disabled child.
- Don’t work in a stressful, low-paid manual job.
- Don’t live in damp, low-quality housing or be homeless.
- Be able to afford to pay for social activities and annual holidays.
- Don’t be a lone parent.
- Claim all benefits to which you are entitled.
- Be able to afford to own a car.
- Use education to improve your socio-economic position.
This ironic set of advice illustrates the fact that up to four-fifths of the underlying causes of poor health are outside the control of the individual — and of health services. Some of those causes are due to our age, our gender or our genes, but between one-third and one-half are due to what’s known as social, economic and environmental determinants — things like our income, the social connections we have or don’t have, and the material settings where we live and work.
It is ten years since economists David Stuckler and Sanjay Basu published their powerful book The Body Economic — Why Austerity Kills, arguing that being poor is not just uncomfortable. It costs lives, because financial poverty — and the associated loss of opportunity — is linked, through multiple different pathways, to poor health and shorter life expectancy.
Whoever wins the next election needs to put front and centre the fact that many, many illnesses, especially in the most vulnerable groups, could be prevented if we put policies in place to reduce the shocking and widening socio-economic inequities that characterise contemporary UK society. Evidence presented by people like Marmot, Stuckler, Danny Dorling and their coauthors, for example, suggests an important role for policies such as progressive taxation, a minimum basic income and security of that income, decent housing and living conditions, humane working conditions and employment rights, high-quality basic education for all, a strong and comprehensive social care system, and safe working environments and public spaces. We need these things because they are fair and reasonable and socially just, but also because they will lead to better health, less sickness absence, less long-term disability, more people of working age paying tax, and lower costs to the health service.
Here is another example of how good evidence-based policy is crucial. In 2020, a coroner ruled that the death of a girl in south London was directly linked to air pollution. Since then, The Environment Act has become law, providing the government with the power to set binding targets for outdoor air quality, water, biodiversity and waste reduction. The next government needs to prioritise these targets and also — given that many respiratory diseases including covid-19 are transmitted through stale and contaminated air — set targets for indoor air.
It’s also imperative to improve access to healthcare. There are literally millions of people waiting for a crucial appointment and more than 10,000 who have been waiting more than 18 months. And yet in numerous physical and mental conditions, there is evidence that early assessment and prompt intervention has a good chance of reducing suffering, getting the person back to work or school, and improving their long-term outlook.
As well as this, our increasingly impersonal and technology-driven service can fail older people with complex needs as they enter their twilight years. GPs are not just the gatekeepers who control access to specialist care; they are also generalists who get to know their patients well and manage the majority of conditions without onward referral. Transactional care — the ‘easyJet’ version of primary care in which each contact is superficial, task-focused and with a different person — leads to repeat contacts from unsatisfied patients as well as to over-investigation, over-prescribing and over-referral, and this in turn leads to higher overall service costs and worse health outcomes. If you want to make a health service more efficient, the cheapest way to do it is strengthen primary care.
Parties whose election manifestos suggest that they plan to be profligate with public money may get a hard time at the ballot box. But after 12 years of under-investment, the NHS and social care are currently perilously underfunded and lacking resilience. But whilst investment in the short term may look costly, there will be economic as well as health dividends if we can return to a service that is funded sufficiently for every GP practice to be able to give an appointment to everyone who needs to see a doctor or nurse; where every person who is unable to work is restored quickly to productivity; and where a person can grow old and remain fulfilled in their own home even as chronic illness affects them.
Let’s also not forget that the NHS is the UK’s largest employer. In every region across the country, it boosts the economy by providing jobs, as well as by contributing to research and innovation. It produces — or at least, until recently it used to produce — a highly-trained and highly-motivated healthcare workforce that was the envy of the world. But 13 years of wage stagnation, understaffing, premature retirement and general workforce attrition have taken a heavy toll on the existing NHS workforce, many of whom went through life-changing levels of personal and occupational stress during the pandemic. Junior doctors are emigrating in droves. This situation is unsustainable. We must address retention of NHS staff as well as recruitment, by giving them the clear message: we value you; we care about your wellbeing; we want to keep you; we will train you.
So here’s my advice to parties wanting to get elected. First, remember the social determinants of health and our moral responsibility to address them. It’s okay to care about the sick and vulnerable. It’s okay for the welfare state to be a safety-net. Second, attend to the upstream causes of ill health which lie outside the healthcare system. Take bold steps to reduce poverty. Improve equity of opportunity in every aspect of society. Third, view the NHS as a public good. Renew and strengthen its core services. Value and invest in its staff. Resist the temptation to fragment it and outsource its work. Fourth, strengthen primary care, since it’s the cheapest way to strengthen the service as a whole. Fifth, be honest that all this will cost money, and make clear what people will get for that investment.
About the author
Trish Greenhalgh is Professor of Primary Care Health Sciences and Fellow of Green Templeton College at the University of Oxford. She has a doctorate in diabetes care and an MBA in Higher Education Management. She leads a programme of research at the interface between the social sciences and medicine, working across primary and secondary care. Trish is the author of over 400 peer-reviewed publications and 16 textbooks. She was awarded the OBE for Services to Medicine by Her Majesty the Queen in 2001 and made a Fellow of the UK Academy of Medical Sciences in 2014. She is also a Fellow of the UK Royal College of Physicians, Royal College of General Practitioners, Faculty of Clinical Informatics and Faculty of Public Health. In 2021 she was elected to the Fellowship of United States National Academy of Medicine.
Photo credit: Stephen Andrews, Unsplash